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CONTACT INFORMATION

District

Name of Superintendent: Phone:


Mailing Address: Email:
City: State/Zip:

LICENSE TYPE QUANTITY PRICE

TOTAL
Executive Elder:
District Elder:
Ordained Elder:
Ordained Minister
Pro Tempore Minister:
Evangelist/Minister:
Consecrated Female:
Missionary/ Evangelist/ Minister:
Deacon:
Deacon (National Finance Board):
Missionary (F):
Missionary (M):

TOTALS:

PAYMENT METHOD:

Signature Date

CHURCH OF GOD BY FAITH, INC. • 2409 Old Middleburg Road N • Jacksonville, FL 32210
Web: www.cogbf.org • Email: info@cogbf.org • Phone: 904-779-5469 • Fax: 904-779-5399
Form: #7

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